176803831-8-1-2024-21-AS-BMOS-D7WQX7-20240807123305

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 176803831
Report Date: 08/01/2024
Date Signed: 08/01/2024 01:56:28 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/15/2024 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20240515141136

FACILITY NAME:	ORCHARD PARK SENIOR LIVING COMMUNITY		FACILITY NUMBER:	176803831
ADMINISTRATOR:	AUDREANNA VERLING		FACILITY TYPE:	740
ADDRESS:	14789 BURNS VALLEY ROAD		TELEPHONE:	(707) 995-1900
CITY:	CLEARLAKE	STATE: CA	ZIP CODE:	95422
CAPACITY:	56	CENSUS: 32	DATE:	08/01/2024
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Danelle Santoni, Administrator		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Resident sustained an unexplained injury

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hansen arrived unannounced on this day for the purpose of delivering findings of the above allegation. LPA met with Danelle Santoni, Administrator.

During the course of this investigation LPA conducted interviews, made observations, and obtained documents regarding the allegation.

Resident sustained unexplained injury – Complaint alleges resident sustained a bruise of unknown origin. Documents obtained during investigation from facility indicate resident (R1) had a fall while away from facility on 5/8/2024 and was taken to the hospital where R1 was diagnosed with a fracture of the lower left arm, that now has a cast. LPA’s interview with outside medical professional on 5/20/2024 indicates R1 had a bruise right above the top of the cast, the size of a thumb print that was observed on 5/13/2024. LPA conducted multiple interviews with staff.
Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240515141136

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ORCHARD PARK SENIOR LIVING COMMUNITY	FACILITY NUMBER: 176803831
	VISIT DATE: 08/01/2024

NARRATIVE

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Continued from LIC9099-

Interview with R1 was inconclusive and did not remember where or how the bruise happened. Law Enforcement investigation report obtained states, at the time of report the allegation was unfounded. Based on review of reports and interviews the department is not able to prove or disprove resident sustained unexplained injuries while in care. Therefore, the allegation is Unsubstantiated.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

LIC9099 (FAS) - (06/04)

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